{"id":4992,"date":"2024-05-15T10:38:03","date_gmt":"2024-05-15T15:38:03","guid":{"rendered":"https:\/\/www.apexosn.com\/formulario-de-paciente-nuevo-formularios-de-consentimiento\/"},"modified":"2024-07-23T15:03:25","modified_gmt":"2024-07-23T20:03:25","slug":"formulario-de-paciente-nuevo-formularios-de-consentimiento","status":"publish","type":"page","link":"https:\/\/www.apexosn.com\/es\/formulario-de-paciente-nuevo-formularios-de-consentimiento\/","title":{"rendered":"Formulario de paciente nuevo Formularios de consentimiento"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4992\" class=\"elementor elementor-4992 elementor-3516\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3508a4f e-con-full e-flex e-con e-parent\" data-id=\"3508a4f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4e1054c elementor-widget elementor-widget-template\" data-id=\"4e1054c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"template.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-template\">\n\t\t\t\t\t<div data-elementor-type=\"section\" data-elementor-id=\"610\" class=\"elementor elementor-610\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c535fe5 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"c535fe5\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7d1f7d2\" data-id=\"7d1f7d2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-47e66df default-hero-title elementor-widget elementor-widget-shortcode\" data-id=\"47e66df\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><h1 class=\"elementor-post__title\">Formulario de paciente nuevo Formularios de consentimiento<\/h1><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-835e4d8 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"835e4d8\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7bb86ff\" data-id=\"7bb86ff\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9c7936c elementor-widget elementor-widget-shortcode\" data-id=\"9c7936c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><nav aria-label=\"breadcrumbs\" class=\"rank-math-breadcrumb\"><p><span class=\"last\">Home<\/span><\/p><\/nav><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-01fa191 e-flex e-con-boxed e-con e-parent\" data-id=\"01fa191\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-be0fb86 elementor-widget elementor-widget-heading\" data-id=\"be0fb86\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Condiciones de los servicios y consentimiento para el tratamiento\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5e2714a elementor-widget elementor-widget-shortcode\" data-id=\"5e2714a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' ><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/4992#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>9<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_11' style='width:11%;'><span>11%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_86\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Instagram<\/label><div class='ginput_container'><input name='input_86' id='input_1_86' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_86'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CONDITIONS OF SERVICES AND CONSENT TO TREATMENT<\/h3><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>In consideration of services provided by Apex Orthopaedics Spine &amp; Neurology (\u201cProvider\u201d), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:<\/p>\n<ol>\n<li><strong>Consent to Routine Medical Treatment\/Services. <\/strong>Patient consents to the rendering of Medical Treatment\/Services as considered necessary and appropriate by the attending physician or other practitioner, a member of the Provider\u2019s medical staff who has requested care and treatment of Patient, and others with staff privileges at Provider. Medical Treatment\/Services may be performed by \"Healthcare Professionals\" (physicians, radiologist, nurses, technologists, technicians, physician assistants or other healthcare professionals). Patient authorizes the attending or other practitioner, the medical staff of Provider and Provider to provide Medical Treatment\/Services ordered or requested by attending or another practitioner and those acting in his or her place. <strong>The consent to receive \u201cMedical Treatment\/Services\u201d includes but is not limited to: out-patient care; examinations (MRI, x-ray or otherwise); laboratory procedures; medications; drugs; supplies; anesthesia; surgical procedures and medical treatments; recording\/filming for internal purposes (Patient\u2019s name, identification, diagnosis, treatment, performance improvement, education, safety, security) and other services which Patient may receive. <\/strong>Patient consents to treatment by Provider with the understanding that Patient will furnish accurate information regarding their injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. Patient\u2019s non-compliance with the plan of treatment may result in the refusal of further care and discharge from Provider.<\/li>\n<li><strong>Legal Relationship between Facility and Physician.<\/strong> Apex Orthopaedics Spine &amp; Neurology, PLLC; Apex Orthopaedics Spine &amp; Neurology of South Carolina, LLC; Georgia Spine &amp; Orthopaedics, and Surgery Center of Roswell are physician owned facilities and your physician may have a financial interest in the center. Patient has the right to choose where Patient receives medical and surgical services including an entity in which Patient\u2019s physician may have a financial relationship. Patient will not be treated differently by Patient\u2019s physician if Patient opts to use a different If desired, Patient\u2019sphysician can provide information about alternative providers. By accepting this acknowledgment of disclosure, PATIENT acknowledges that PATIENT has read and understand the foregoing notice regarding physician ownership.<\/li>\n<li><strong>Explanation of Risk and Treatment Alternatives. <\/strong>Patient acknowledges that the practice of medicine is not an exact science and that <strong>NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO THE PATIENT <\/strong>concerning the outcome and\/or result of any <strong>Medical Treatment\/Services<\/strong>. While routinely performed without incident, there may be material risks associated with each of these <strong>Medical Treatment\/Services<\/strong>. Patient understands that it is not possible to list every risk for every <strong>Medical Treatment\/Services <\/strong>and that this form only attempts to identify the most common material risks and the alternatives (if any) associated with the <strong>Medical Treatment\/Services<\/strong>. Patient also understands that various Healthcare Professionals may have differing opinions as to what constitutes material risks and alternative <strong>Medical Treatment\/Services. <em>By signing this form<\/em><\/strong>: Patient consents to Healthcare Professionals performing <strong>Medical Treatment\/Services <\/strong>as they may deem reasonably necessary or desirable in the exercise of their professional judgment, <strong>including those Medical Treatment\/Services that may be unforeseen or not known to be needed at the time this consent is obtained; <\/strong>and Patient acknowledges that Patient has been informed in general terms of the nature and purpose of the <strong>Medical Treatment\/Services<\/strong>; the material risks of the <strong>Medical Treatment\/Services <\/strong>and practical alternatives to the <strong>Medical Treatment\/Services<\/strong>. The <strong>Medical Treatment\/Services <\/strong>may include, but are not limited to the following:<\/li>\n<li>a) &nbsp;<strong>Needle Sticks, <\/strong>such as shots, injections, intravenous lines or intravenous injections (lVs). The material risks associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal or topical medications (each of which may be less effective).<\/li>\n<li>b) &nbsp;<strong>Physical Tests, Assessments and Treatments <\/strong>such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscular-skeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures, no practical alternatives exist.<\/li>\n<li>c) &nbsp;<strong>Administration of Medications <\/strong>via appropriate route whether orally, rectally, topically or through Patient\u2019s eyes, ears or nostrils, etc. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration, no practical alternatives exist.<\/li>\n<li>d) <strong>Insertion of Internal Tubes <\/strong>such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and\/or difficulty urinating after catheter removal. Apart from external collection devices, no practical alternatives exist.<\/li>\n<li>e) &nbsp;<strong>Radiological Studies <\/strong>such as X-rays or MRI scans. The material risks associated with these types of Procedures include, but are not limited to, radiation exposure.<\/li>\n<\/ol>\n<p>If Patient has any questions or concerns regarding these <strong>Medical Treatment\/Services<\/strong>, Patient will ask Patient\u2019s attending provider to provide Patient with additional information. Patient also understands that Patient\u2019s attending or other provider may ask Patient to sign additional informed consent documents concerning these or other <strong>Medical Treatment\/Services<\/strong>.<\/p>\n<ol start=\"4\">\n<li><strong>Healthcare Practitioners in Training. <\/strong>Patient recognizes that among those who may attend to Patient at Provider\u2019s offices\/clinics are medical, nursing and other health care personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their medical education. There also may be present from time to time a medical product or medical device representative. Consent is hereby given for the presence and participation of such persons as deemed appropriate by the attending physician.<\/li>\n<li><strong>Authorization to Release Information.<\/strong> Provider is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of same and\/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. SIS, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient\u2019s record include, but are not limited to, insurance company(s), their agents or other third party payor and\/or government or social service agencies which may or will pay for any part of the medical\/hospital expenses incurred or authorized by representatives of SIS, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient\u2019s physician or as requested by Patient or Patient\u2019s family for post-hospital care. <strong>PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT\u2019S RECORDS WILL BE AVAILABLE TO ALL OF PROVIDER\u2019S AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-PROVIDER AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE. <\/strong>Patient also agrees, in order for Provider to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. Provider or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded\/artificial voice messages and\/or use of an automatic dialing device, as applicable.<\/li>\n<\/ol>\n<p><strong>Validity of Form. <\/strong>Patient acknowledges that a copy, or an electronic version of this document may be used in place of and is as valid as the original. Patient understands that the Healthcare Professionals participating in the Patient\u2019s care will rely on Patient\u2019s documented medical history, as well as other information obtained from Patient, Patient\u2019s family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient\u2019s medical history and conditions.<\/p>\n<p><strong>Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient\u2019s legal representative or is duly authorized by the Patient as the Patient\u2019s general agent to sign this form. &nbsp;<\/strong><\/p><\/div><fieldset id=\"field_1_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_2'>\n                            \n                            <span id='input_1_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_2_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_1_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_3_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_4' id='input_1_4_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_4_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_4' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_4_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_4_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_4_data' name='input_1_4_data' value=''><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-7' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION<\/h3><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION<\/strong><\/p>\n<p>GENERAL INFORMATION<\/p>\n<p>Patient understands Apex Orthopaedics Spine &amp; Neurology (\u201cProvider\u201d) is licensed to dispense certain medications (\u201cMedications\u201d). Patient understands Provider is willing to mail Medications to Patient\u2019s home address via First - Class Mail. Patient understands there is a risk, however, that: (i) someone may steal Medications out of Patient\u2019s mailbox, (ii) a family member or other person authorized to collect the mail from Patient\u2019s mailbox may wrongfully take Medications, (iii) Medications may get lost or stolen in transit from their office to Patient\u2019s mailbox, or(iv) Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Medications is that Patient\u2019s Protected Health Information(PHI) is discovered by an unauthorized party. Patient understands Provider is not responsible if sending Medications results in an unauthorized person seeing Patient\u2019s PHI or obtaining Medications. Knowing these risks and accepting the liability and responsibility for same, Patient agrees and authorizes Provider to mail Patient\u2019s Medications to Patient\u2019s home address.<\/p>\n<p>ACCEPTANCE, CONSENT, AND WAIVER<\/p>\n<p>Patient agrees to allow Provider to mail Patient\u2019s prescriptions directly to the address Patient provided. This mailing will include Patient\u2019s PHI, such as Patient\u2019s name and the medication that Patient am taking and may include other sensitive facts about Patient\u2019s health. Patient understands that if another person accesses Patient\u2019s prescription, that person will see Patient\u2019s PHI. If Patient do not want to accept the risk that someone may take Patient\u2019s prescription and\/ or access Patient\u2019s PHI, Patient should not agree to allow Provider to mail Patient\u2019s prescriptions to Patient.<\/p>\n<p>Patient accepts these risks and agrees that Provider may mail Patient\u2019s prescriptions to Patient via First-Class Mail. Patient agrees to inform Provider immediately if Patient\u2019s address changes. Patient will not hold Provider responsible if Patient\u2019s PHI is seen by an unauthorized person or Patient\u2019s medications are taken\/ obtained by an unauthorized party. Patient RELEASES, WAIVES, DISCHARGES AND PROMISES NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST PROVIDER FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.<\/p>\n<p>This form gives you the facts and risks involved in receiving Patient\u2019s Medications by mail. By accepting this form, Patient confirms that Patient has read, understands, and agrees with these Terms of Use for receiving Patient\u2019s Medications by mail.<\/p><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_9'>\n                            \n                            <span id='input_1_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_1_9_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_9_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_1_9_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_9_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_1_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_10_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_10' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_1_11_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_11_1' id='input_1_11_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_1_11_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_11_2' id='input_1_11_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_1_11_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_11_3' id='input_1_11_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_11_4_container' >\n                                        <input type='text' name='input_11.4' id='input_1_11_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_11_4' id='input_1_11_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_1_11_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_11_5' id='input_1_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_11_6_container' >\n                                        <select name='input_11.6' id='input_1_11_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_1_11_6' id='input_1_11_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_12' id='input_1_12_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_12_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_12' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_12_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_12_resetbutton' src='data:image\/png;base64,iVBORw0KGgoAAAANSUhEUgAAABgAAAAYCAYAAADgdz34AAAAGXRFWHRTb2Z0d2FyZQBBZG9iZSBJbWFnZVJlYWR5ccllPAAAAtRJREFUeNrsld9rklEYx32nc7i2GulGtZg6XJbJyBeJzbGZJJVuAyFD7D8QumiG7nLXQuw6dtHN7oYwFtIgDG+2CGQtGf1grBpWIkPHaDpJZvZ95F2cqfPHRTfRgY\/H85znfb7nPc85z8sVi0XR32zcf4GmBTiOk8GWY8YSdEpwHpwG7eAA\/ABJsA3\/w5MEJOUGi8VyCUFFeCiGvlcsFvOFQqGtzK1d4Bzmr8DvDfy\/NyTgcDj6I5GIGA91YdiN4CW7RqNp83g8fZ2dna17e3v5ubm5r1tbWz8F8WH4v4PIh7oCTOumH4VCIQkGg6axsTElgkRhyoJTXq\/33srKStzpdL5KpVK0RVcxvw+Rb40KlNr09LTSbDZH8HcJ\/DqyY2sksE9Go1GHVqsN5fP5Yk9Pz3WIJNmctNQT8Pl8n\/DQZza40CjIokqlerywsMCTYWdnpwVjTb0kF1dXVy2sLR6Pn4HIJnu6mLZht9s3KUeUE7VarYPt459ZOqZlKMFEFRRVfI+QzMzMeBHOOTAw4GbnKt4AK6Vte0\/nHA6pBu\/T4ejoqAgnS4dTlT82U74aJOourYTn+ds1VlyNm+AReMjaK5LsdrvpxoqSyWSX8DbVSwDHtYJ+hi9gETxl\/SoCWK1WGfWJRKLQ0dGhO0kAq5MGAoFB\/OVZXC6XtqYAzvamwWCgMiDK5XKXsSL5CRpZv98vnp+fH2SNJpPpYk0BlIIXSJaB\/lOZkEqlNyCi4ahAHd8iajGUj41a2a+2xzmj0fgsFAoN0QA3lAJfAxMISDeVpx7jSbJnMplSOZ6amuptVIBaZHx8\/G0sFruj1+tlgo2KWh\/oF3opGWl+bW3t1uzsrHJ5eXm42Q+OGW\/wADc7gYe3w+Fwen19\/YByhMMgt9lsqpGRkQvYxifwfQnup9PprFwuX2rmi0ZvYAdDwurPgl1A9ek1eE7byqYR7P873+TfAgwATQiKdubVli0AAAAASUVORK5CYII=' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_12_data' name='input_1_12_data' value=''><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION<\/h3><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PHARMACY CONSENT<\/h3><\/div><fieldset id=\"field_1_25\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_25'>\n                            \n                            <span id='input_1_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_1_25_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_25_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_1_25_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_25_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_26\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_1_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_26_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_26_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_26' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>GENERAL INFORMATION<\/p>\n<p>I understand that at my direction my Provider will transmit my prescriptions electronically as permitted, to the pharmacy that I delegate as my primary pharmacy provider. Prescription data collected will be stored in Provider\u2019s practice electronic medical records system and will become a part of my personal medical record. I hereby give permission to allow Provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give Provider permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS\/HIV and medications used to treat mental health issues.<\/p>\n<p>THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ\/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ\/ COMPLETED FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL MEDICAL PROFESSIONALS EMPLOYED BY PROVIDER.<\/p><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_28' id='input_1_28_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_28_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_28' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_28_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_28_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_28_data' name='input_1_28_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_29' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_29' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ASSIGNMENT OF BENEFITS AND PATIENT RESPONSIBILITY<\/h3><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Patient assigns and appoints Apex Orthopaedics Spine & Neurology (\u201cProvider\u201d), as its authorized representative and billing agent with the right to pursue payment for benefits, and take any and all necessary steps, including pursuing administrative appeals, requesting disclosures and remedies, filing suit and all causes of action wholly in my stand for benefit payment of all medical benefits otherwise payable to the Patient for medical services, treatments, therapies, and\/or medications rendered or provided by the Provider under the Plan, regardless of the Provider\u2019s managed care network participation status. The Patient hereby appoints the Provider, its billing agent and\/or the Patient\u2019s appointed business associates, the Patient\u2019s rights, title, and interests in and to, and related to the recovery of, any and all benefits which the Patient is entitled to receive under the Plan or insurance policy and authorizes the Provider to release all medial information necessary to pursue and process the Patient\u2019s benefits and claims thereunder. Patient certifies that the health insurance information that Patient provided is accurate and that Patient is responsible for keeping it updated. Patient hereby authorize Provider to submit claims on Patient\u2019s behalf to the benefit plan (or its administrator) to be paid in full compliance of governing laws. Patient also hereby instructs its benefits plan (or its administrator) to pay the Provider directly for services rendered to Patient. To the extent that my current policy prohibits direct payment to provider, Patient hereby instructs and directs its benefit plan (or its administrator) to provide governing plan documentation stating such non-assignment to Patient and the Provider upon request and its standing to governing laws. Upon proof of such non-assignment, Patient instructs benefit plan (or its administrator) to make check payable to Patient and mail it directly to Provider. Patient understands there are state and federal consumer protections that support even for out of network providers that may be associated with Patient\u2019s care or surgery, that Patient is responsible for co-payments, co-insurance, and deductibles at no more than Patient\u2019s in-network cost share rate. Patient understands, agrees and hereby certifies that Patient is obligated to pay, as charge and billed for global service charges, regardless of if the above services are covered under Patient\u2019s health insurance or plan. Patient understands that \u201cDeductible\u201d is defined, under the Uniform Glossary from ERISA & the Patient Protection & Affordable Care Act (\u201cACA\u201d) as: \u201cThe amount [Patient] owes for healthcare services [Patient\u2019s] health insurance or plan covers before [Patient\u2019s] health insurance or plan begins to pay,\u201d and that Patient has no knowledge of any plan exclusion or limitation for the charges for healthcare services rendered by the above listed provider, in case that Patient can\u2019t afford to pay 100% deductible. Patient understands the payments are due at the time of the services unless otherwise applicable to any PPO or ACA discount once Patient\u2019s claim for benefits is processed in full compliance with plan terms and governing laws. Patient understands Patient is fully protected against any unexpected medical bills or charges by my provider\u2019s appliable ACA or indigency discount policy; including any non-complaint or arbitrary and capricious PPO discount of Re-pricing Discounts received from Patient\u2019s health insurance plan. Patient\u2019s satisfaction is guaranteed in connection with Provider\u2019s proactive reasonable efforts to collect or make a good faith determination for ACA Discount qualifications solely based on Patient\u2019s unique ability to pay and individual health need. Patient hereby assigns billed charges for healthcare services rendered as Patient\u2019s legal claims to the above listed Provider as full payment, as Patient authorized representative, and an ERISA or ACA claimant, to claim or legally pursue proper payment of benefits from my health plan or insurance.<\/p>\n\n<p>Patient hereby designates, authorizes and appoints Provider, its attorney or other designated business associate and a Patient\u2019s authorized representative to: (1) release any information necessary to Patient\u2019s health benefit plan (or its administer) regarding Patient\u2019s illness and treatments; (2) process insurance claims generated in the course of examination or treatment; (3) To file and participate in any administrative or judicial review process; (4) to give the provider and its attorneys standing to pursue payment and file suit for benefits and any fiduciary breach and all causes of action, wholly in Patient\u2019s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach and all causes of action available under ERISA and Section 502, 27 \u00a7 U.S.C. 1132(a); (5) to pursue all necessary benefit payments, appeal rights, remedies and all causes of action, wholly in Patient\u2019s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach or failure by Patient\u2019s plan, its fiduciary and\/or its claims administrator to comply with 29 USC \u00a7 1132 and (7) allow a photocopy of Patient\u2019s signature to be used to process insurance claims. This authorization includes all entitled benefit payments, rights and remedies due under Patient\u2019s governing Health and Welfare Plan or policy, to include all benefits entitled for all services rendered and ordered by Patient\u2019s treating physician. This authorization will remain in effect until all benefits are paid in full compliance of applicable federal and state laws. Patient hereby confirms and ratifies all actions taken by Patient\u2019s Provider, its attorneys or designated business associates to make any request, file and obtain appeals information, receive any notice in connection with patient\u2019s healthcare services, benefits, appeals, take legal action or other rights, wholly in Patient\u2019s stead. Further, Patient hereby authorizes Patient\u2019s plan administrator, fiduciary, insurer, and\/or attorney to release to the above-named health care provider or its designated business associated in any and all relevant Plans and claim documents, requested disclosures, complete insurance policy, and\/or settlement information upon request from Provider, its attorneys or designated business associate in order to secure and claim such medical benefits. Patient authorizes the release or disclosure of Patient\u2019s protected health information to Patient\u2019s authorized representative in order to secure and claim medical benefits due: (1) obtain information or submit evidence regarding the claim to the same extent as Patient; (2) make statements about facts or law; (3) act as Patient\u2019s authorized representative in connection with filing, providing or receiving notice of any claim or appeal proceedings, to include any external review by applicable state and Federal External Review Process. I understand that I will be held financially responsible for all fees accumulated for collection agency fees. Administrative fees, attorney fees and court costs incurred by the provider listed above for any delinquent account requiring outside collection assistance, to the fullest extent of the law. Patient understands revocation of this appointment will not affect any action taken in reliance on this appointment before Patient\u2019s written notice of revocation is received. Unless revoked in writing, this assignment is valid for any and all requested administrative and judicial reviews rightfully due to Patient under Patient\u2019s governing plan or policy and to the fullest extent permitted by law. Patient, by signing this form, confirms appointment of authorized representative, the scope of Patient\u2019s authorized representative\u2019s authority, and the option of revoking of this appointment.<\/p>\n\n<p>Patient understands Provider will attempt to obtain eligibility information, authorizations, and referrals on Patient\u2019s behalf. Patient understands that it is in Patient\u2019s best interest to verify with Patient\u2019s insurance carrier what Patient\u2019s benefits are and if  Provider is participating on Patient\u2019s plan. Provider does not guarantee benefits or coverage at the time of service. Patient also understands that any amounts not paid by Patient\u2019s health insurance or plan is Patient\u2019s responsibility and such payment is due at the time of service.<\/p>\n\n<p>Patient hereby assigns and authorizes payment directly to Provider of: (i) any private healthcare insurance, (ii) medicalpayment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resultingfrom the liability of a third party, payable by any party, organization, attorney, etc., to or for Patient, unless and until Patient\u2019s account with Provider for the services or series of related services provided by the Provider (collectively, the \u201cServices\u201d) is paid in full, upon discharge or completion of the Services. Patient hereby authorizes Provider to apply and file for allsuch payments referenced herein on Patient\u2019s behalf, and direct that such payments be made directly to Provider.<\/p><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_33'>\n                            \n                            <span id='input_1_33_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.3' id='input_1_33_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_33_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_33_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.6' id='input_1_33_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_33_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_34\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_34' id='input_1_34' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_34_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_34_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_34' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_41' id='input_1_41_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_41_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_41' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_41_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_41_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_41_data' name='input_1_41_data' value=''><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PATIENT FINANCIAL RESPONSIBILITIES<\/h3><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Patient understands that by receiving services provided by Provider (collectively, the \u201cServices\u201d) PATIENT is personallyresponsible for any portion of the Provider\u2019s invoice(s) for Services that remains outstanding. Patient further agrees to execute any necessary documents to direct all third-party benefits and other payments for Services to Provider.<\/p>\n\n<p>Patient understands that Provider has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If a lawsuit is filed to collect on Patient\u2019s account, exclusive jurisdiction shall be in the state and federal courts of North Carolina. Patient waves all objections to personal jurisdiction and venue in North Carolina. Patient agrees to pay Provider\u2019s reasonable attorneys\u2019 fees and costs incurred collecting on any outstanding amounts due to Provider.<\/p><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_42'>\n                            \n                            <span id='input_1_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_1_42_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_42_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_1_42_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_42_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_43\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_43' id='input_1_43' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_43_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_43_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_43' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_44' id='input_1_44_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_44_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_44' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_44_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_44_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_44_data' name='input_1_44_data' value=''><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_49' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_49' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-49' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HIPAA ACKNOWLEDGEMENT<\/h3><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>In accordance with the Health Insurance Portability and Accountability Act (HIPAA), by accepting this form, Patientacknowledges that Patient was given access to and offered a copy of the Notice of Privacy Practices for Apex Orthopaedics Spine & Neurology.<\/p><\/div><fieldset id=\"field_1_51\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_51'>\n                            \n                            <span id='input_1_51_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.3' id='input_1_51_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_51_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_51_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.6' id='input_1_51_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_51_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_1_52' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_52_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_52' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_53' id='input_1_53_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_53_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_53' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_53_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_53_resetbutton' src='data:image\/png;base64,iVBORw0KGgoAAAANSUhEUgAAABgAAAAYCAYAAADgdz34AAAAGXRFWHRTb2Z0d2FyZQBBZG9iZSBJbWFnZVJlYWR5ccllPAAAAtRJREFUeNrsld9rklEYx32nc7i2GulGtZg6XJbJyBeJzbGZJJVuAyFD7D8QumiG7nLXQuw6dtHN7oYwFtIgDG+2CGQtGf1grBpWIkPHaDpJZvZ95F2cqfPHRTfRgY\/H85znfb7nPc85z8sVi0XR32zcf4GmBTiOk8GWY8YSdEpwHpwG7eAA\/ABJsA3\/w5MEJOUGi8VyCUFFeCiGvlcsFvOFQqGtzK1d4Bzmr8DvDfy\/NyTgcDj6I5GIGA91YdiN4CW7RqNp83g8fZ2dna17e3v5ubm5r1tbWz8F8WH4v4PIh7oCTOumH4VCIQkGg6axsTElgkRhyoJTXq\/33srKStzpdL5KpVK0RVcxvw+Rb40KlNr09LTSbDZH8HcJ\/DqyY2sksE9Go1GHVqsN5fP5Yk9Pz3WIJNmctNQT8Pl8n\/DQZza40CjIokqlerywsMCTYWdnpwVjTb0kF1dXVy2sLR6Pn4HIJnu6mLZht9s3KUeUE7VarYPt459ZOqZlKMFEFRRVfI+QzMzMeBHOOTAw4GbnKt4AK6Vte0\/nHA6pBu\/T4ejoqAgnS4dTlT82U74aJOourYTn+ds1VlyNm+AReMjaK5LsdrvpxoqSyWSX8DbVSwDHtYJ+hi9gETxl\/SoCWK1WGfWJRKLQ0dGhO0kAq5MGAoFB\/OVZXC6XtqYAzvamwWCgMiDK5XKXsSL5CRpZv98vnp+fH2SNJpPpYk0BlIIXSJaB\/lOZkEqlNyCi4ahAHd8iajGUj41a2a+2xzmj0fgsFAoN0QA3lAJfAxMISDeVpx7jSbJnMplSOZ6amuptVIBaZHx8\/G0sFruj1+tlgo2KWh\/oF3opGWl+bW3t1uzsrHJ5eXm42Q+OGW\/wADc7gYe3w+Fwen19\/YByhMMgt9lsqpGRkQvYxifwfQnup9PprFwuX2rmi0ZvYAdDwurPgl1A9ek1eE7byqYR7P873+TfAgwATQiKdubVli0AAAAASUVORK5CYII=' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_53_data' name='input_1_53_data' value=''><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_56' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_56' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-56' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_57\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_57'>\n                            \n                            <span id='input_1_57_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.3' id='input_1_57_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_57_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_57_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.6' id='input_1_57_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_57_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>Parent\/Guardian First and Last Name (if patient under 18 years old):<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>Spouse\/Other: First and Last Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Current Mobile Phone Number(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_60' id='input_1_60' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Current Mobile Phone Number(s):<\/label><div class='ginput_container ginput_container_phone'><input name='input_61' id='input_1_61' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Current Email Address:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_62' id='input_1_62' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_63'>Current Email Address #2:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_63' id='input_1_63' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Patient hereby authorize Provider to leave Protected Heath Information (\u201cPHI\u201d) pertaining to Patient\u2019s care by voicemail\/email\/text and will assume responsibility to notify them whenever this information changes. Patient authorizesProvider to leave messages with the person(s) Patient has designated as Patient\u2019s approved contacts or emergency contacts. Patient understands that PHI used or disclosed pursuant to this Authorization may be subject to re-disclosure bythe recipient and no longer protected by Federal or State Law. Patient understands that Patient have the right to revokethis authorization at any time. Patient understands that in order to revoke this authorization, Patient must do so inwriting and present Patient\u2019s revocation to Provider. Patient understands that the revocation will not apply to information that has already been used or disclosed in response to this authorization. Patient understands that this authorization isvalid unless and until written notice is provided to revoke this authorization. Patient understands that Provider cannot require Patient to sign this authorization as a condition of treatment unless the provision of health care by Provider is for the sole purpose of creating PHI for disclosure to a third party legally authorized to receive such information.<\/p>\n<p>By providing a telephone number, Patient expressly consent and authorize SIS, any practitioner or clinical provider as well as any of their related entities, agents, or contractors including but not limited to schedulers, debt collectors, and other contracted staff (collectively referred to herein as \u201cProvider\u201d) to contact Patient through the use of text messages and any dialing equipment (including a dialer, automatic telephone dial system, and\/or interactive voice recognition system) and\/or artificial or prerecorded voice or message. Patient expressly agree that such automated calls and\/or text messages may be made to any telephone number (including numbers assigned to any cellular or other service for which Patient may be charged for the call) used by or associated with Patient and obtained through any source including but not limited to any number Patient is providing today, have provided previously, or may provide in the future in connection with the medical goods and services and\/or Patient\u2019s account. By providing this express consent, Patient specifically waives any claim Patient may have to the making of such calls, including any claims under the federal or state law and specifically any claim under the Telephone Consumer Protection Act, 47 U.S.C. \u00a7 227. By providing a telephone number, Patient represent that Patient is the subscriber or owner or have the authority to use and provider consent to call the number.<\/p>\n<p>By providing Patient\u2019s email address now or at any time in the future in connection with the medical goods and services provided and\/or Patient\u2019s account, Patient expressly opt-in to the receipt of email communications from Provider for or related to the medical goods or services provided, Patient\u2019s account, and other services such as financial, clinical, and education information including news, changes to health care laws, health coverage, care follow-up, and other health care opportunities, goods, and services. By providing this express consent, Patient specifically waives any claim PATIENT may have for the sending of such emails, including any claim under federal or state law and any claim under the CAN-SPAM Act, 15 U.S.C. \u00a7 7701, et. seq. By providing an email address, Patient represents that Patient is the subscriber or owner of have the authority to use and provider consent to contact the email address.<\/p>\n<p>Patient understands that providing a telephone and\/or email address is not a condition of receiving medical services. Patientunderstands that Patient may revoke Patient\u2019s consent to contact at any time by directly contacting Provider or using the opt-out method that will be identified in the applicable communication. Patient also understands that it is Patient\u2019s responsibility to notify Provider immediately of any change in telephone number or email address.<\/p><\/div><fieldset id=\"field_1_65\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_65'>\n                            \n                            <span id='input_1_65_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_65.3' id='input_1_65_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_65_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_65_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_65.6' id='input_1_65_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_65_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_66\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_66' id='input_1_66' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_66_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_66_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_66' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_67' id='input_1_67_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_67_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_67' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_67_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_67_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_67_data' name='input_1_67_data' value=''><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_68'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_69'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_70'>Patient\/Patient Representative Signature :*<\/label><input type='hidden' value='' name='input_70' id='input_1_70_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_70_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_70' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_70_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_70_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_70_data' name='input_1_70_data' value=''><\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Allow for other individuals to access information as designated by the patient.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_72' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_73\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">AUTHORIZATION TO RELEASE MEDICAL RECORDS<\/h3><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>I authorize the release of medical record(s) of the above person. This information is being released to APEX ORTHOPAEDICS, SPINE &amp; NEUROLOGY for purpose of continued medical care.<\/p>\n<p>\u201cI understand that I have the right to revoke this authorization at any time by presenting a written revocation to the Medical Records Director or designee. I understand that the revocation will not apply to any information that has already been released in response to this authorization.\u201d<\/p>\n<p>This expiration will expire one (1) year from the date of my signature.<\/p>\n<p>\u201cI have read and understand the contents of this authorization and I confirm that the health care provider may use\/disclose my protected health information to the persons and\/or organization named above.\u201d<\/p>\n<p>Please release to:<\/p>\n<p>Apex Orthopaedics, Spine &amp; Neurology<\/p>\n<p>Dr. Erik Bendiks, Dr. Joshua Levy, Dr. Thai Truong,<\/p>\n<p>11650 Alpharetta Hwy<\/p>\n<p>Roswell, GA 30076<\/p>\n<p>Email: <a href=\"mailto:clinical@apexosn.com\">clinical@apexosn.com<\/a><\/p>\n<p>Phone: 704-272-3880<\/p>\n<p>Fax: 704-208-4159<\/p><\/div><fieldset id=\"field_1_75\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_75'>\n                            \n                            <span id='input_1_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.3' id='input_1_75_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_1_75_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.6' id='input_1_75_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_1_75_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_76'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_1_76' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_76_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_76' class='gform_hidden' value='https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>Patient\/Patient Representative Signature :*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><input type='hidden' value='' name='input_77' id='input_1_77_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_77_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_77' width='600' height='180' style='border-style: Dashed; border-width: 1px; border-color: #0D4A5D; background-color:#FFFFFF; cursor: url(https:\/\/www.apexosn.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_77_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_77_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_77_data' name='input_1_77_data' value=''><\/div><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>Relationship to Patient:<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'    placeholder='Relationship to Patient'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Reason Patient is Unable to Sign:<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='large'    placeholder='Reason Patient is Unable to Sign'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_81' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_81' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_9' class='gform_page' data-js='page-field-id-81' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PRIVACY NOTICE<\/h3><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div id=\"field_9_82\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" data-js-reload=\"field_9_82\"><p>THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.<\/p>\n<p>&nbsp;<\/p>\n<p>This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected healthinformation to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your \u201cprotected health information\u201d means any written and oral health information about you, including demographic data thatcan be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.<\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li><strong>Uses and Disclosures of Protected Health Information<\/strong><\/li>\n<\/ol>\n<p>The Organizations may use your protected health information for purposes of providing treatment, obtaining payment fortreatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the facility has obtained your authorization, or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.<\/p>\n<ul>\n<li>We will use and disclose your protected health information to provide, coordinate, or manageyour health care and any related services.<\/li>\n<li>Your protected health information will be used, as needed, to obtain payment for the services that we provide.<\/li>\n<li>We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of Provider and to provide quality care to all patients.<\/li>\n<li>Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose yourprotected health<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ol>\n<li><strong>Uses and Disclosures beyond Treatment, Payment and Health Care Operations Permitted without Authorization or Opportunity to Object<\/strong><\/li>\n<\/ol>\n<p>Federal privacy rules allow us to use or disclose your protected health information without your permission orauthorization for several reasons including the following:<\/p>\n<ul>\n<li>When Legally<\/li>\n<li>When There Are Risks to Public<\/li>\n<li>To Report Suspected Abuse, Neglect or Domestic<\/li>\n<li>To Conduct Health Oversight<\/li>\n<li>In Connection with Judicial and Administrative<\/li>\n<li>For Law Enforcement<\/li>\n<li>For Research<\/li>\n<li>In the Event of a Serious Threat to Health or<\/li>\n<li>For Specified Government<\/li>\n<li>For Worker\u2019s<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>The facility may release your health information to comply with worker\u2019s compensation laws or similar programs.<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATIONS BUT WITH OPPORTUNITY TO OBJECT<\/strong><\/li>\n<\/ul>\n<p>We may disclose your protected health information to your family member if it is directly relevant to the person\u2019s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.<\/p>\n<p>&nbsp;<\/p>\n<p>You may object to these disclosures. If you do not object to these disclosures, in the exercise of our professional judgment, that it is in your best interest for us to make disclosure of information that is directly relevant to that person\u2019sinvolvement with your care, we may disclose your protected health information as described.<\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li><strong>USES AND DISCLOSURES WHICH YOU AUTHORIZE<\/strong><\/li>\n<\/ol>\n<p>Other than stated above, we will not disclose your health information other than with your written authorization. You mayrevoke your authorization in writing at any time except to the extent that we have acted in reliance upon the authorization. We specifically require your written authorization for marketing or the sale of your protected health information. If our facility maintains psychotherapy notes, we will require your written authorization for the use or disclosure of psychotherapy notes other than by the creator of those notes, by the facility for its training programs or for the facility to defend itself in a legal action brought by you.<\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li><strong>YOUR RIGHTS<\/strong><\/li>\n<\/ol>\n<p><strong>&nbsp;<\/strong><\/p>\n<p>You have the following rights regarding your health information:<\/p>\n<ul>\n<li>The right to inspect and copy your protected health information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health A\u201cdesignated record set\u201d contains medical and billing records and any other records that your surgeon and the facility uses for making decisions about you. If information in a \u201c designated record set\u201d is maintained electronically, you may request an electronic copy in a form and format of your choice that is readily producible or, if the form\/format is not readily producible, you will be given a readable electronic copy in a timely manner not to exceed 60 days. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.<\/p>\n<p>&nbsp;<\/p>\n<p>To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request. Please contact our Medical Records Custodian if you have questions about access to your medical record.<\/p>\n<ul>\n<li>The right to request a restriction on uses and disclosures of your protected health You may ask us not touse or disclose certain parts of your protected health information for the purposes of treatment, payment and health care operation. You may request that we do not file a claim to your health plan if an agreed upon amount is paid out-of-pocket. You may also request that we not disclose your health information to family members or friends who maybe involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.<\/li>\n<\/ul>\n<p>The facility is not required to agree to a restriction that you may request unless your request related to a disclosure to a health plan for items or services that were paid in full by you or someone other than the health plan and thedisclosure is not required by law. We will notify you if we deny your request to a restriction. If the facility does agreeto the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer using the contact information below.<\/p>\n<ul>\n<li>The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanationfor your Requests must be made in writing to our Privacy Officer using the contact information below.<\/li>\n<li>The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this Your request may be denied if we did not create the PHI, if the amendment is not part of normal record keeping of PHI, and if theamendment would never be included for inspection by any other group or party and if we believe the record isaccurate and complete without the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copyof any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer whose contact information is listed on the last page of this Privacy Notice. In this written request, you must also provide a reason to support the requested amendment.<\/li>\n<li>The right to receive an You have the right to request an accounting of certain disclosures of your protectedhealth information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without yourauthorization. The request for an accounting must be made in writing to our Privacy Officer. The request shouldspecify the time sought for the accounting. Accounting requests may not be made for periods of time more than six years. We will provide the first accounting you request in any 12-month period without charge, Subsequent accounting requests may be subject to a reasonable cost-based fee.<\/li>\n<li>The right to obtain a paper copy of this Upon request, we will provide a separate paper copy of this noticeeven if you have already received a copy of the notice or have agreed to accept this notice electronically.<\/li>\n<li>PATIENT understand that, by law, Patient\u2019s medical record belongs to Provider. The right to request a copy ofyour medical records in accordance with State and federal Any requests for copies of paper medical records willbe processed within 60 days.<\/li>\n<\/ul>\n<p><strong>&nbsp;<\/strong><\/p>\n<ol>\n<li><strong>OUR DUTIES<\/strong><\/li>\n<\/ol>\n<p>The facility is required by law to maintain the privacy or your health information and report to you any breach of unsecured protected health information. We are also required to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes this Notice, we will post notification at each office location and provide a copy of the revised Notice on our website.<\/p>\n<ul>\n<li><strong>COMPLAINTS<\/strong><\/li>\n<\/ul>\n<p>You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.<\/p>\n<ul>\n<li><strong>CONTACT PERSON<\/strong><\/li>\n<\/ul>\n<p>The facility\u2019s &nbsp;contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to:<\/p>\n<p>Apex Orthopaedics Spine and Neurology<\/p>\n<p>Attn: Privacy Officer<\/p>\n<p>10502 Park Road, Ste 120<\/p>\n<p>Charlotte, NC 28210<\/p>\n<p>Phone: 704-272-3880<\/p>\n<p>Anonymous HIPAA Hotline: 844-333-0850<\/p>\n<p>If you are unable to get your issue resolved, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling 1-877-696-6775.<\/p><\/div><\/div><fieldset id=\"field_1_85\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span 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